Early failure of a tricuspid valve replacement with a mitral valve homograft in a heart transplant recipient

A 24-year-old woman experienced severe tricuspid valve regurgitation 6 years after heart transplantation. Tricuspid valve replacement was performed using a cryopreserved mitral valve homograft. Severe tricuspid valve regurgitation recurred within 4 months, associated with an increase in the panel reactive antibody titers from zero to 72%. Tricuspid valve replacement was repeated with a porcine bioprosthesis with excellent recovery and function for >2 years. The mitral valve homograft displayed inflammatory features consistent with humoral immune-mediated destruction.     

Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis

Background. Seven patients with acute tricuspid endocarditis underwent partial replacement of the tricuspid valve using mitral homograft tissue. Valve function was evaluated at midterm.

Methods. Operative indications were uncontrolled sepsis in all cases associated with heart failure symptoms in 3 patients and septic pulmonary emboli in 2 patients. These patients were referred to our institution after a course of antibiotic treatment ranging from 7 to 12 weeks. Lesions found at the level of the anterior leaflet of the tricuspid valve were vegetations and rupture of more than half of the marginal cords in all patients. Vegetations were also found on the posterior leaflet in 5 patients. In all instances the septal leaflet was free of lesions. The aortic valve was involved in 4 patients and the pulmonary valve in 1 patient. All patients underwent resection of the anterior and posterior leaflets of the tricuspid valve with their corresponding papillary muscles leaving the septal leaflet in place. Replacement of the tricuspid valve was performed through a right longitudinal atrial access, using the anterior leaflet of a mitral homograft alone in 3 patients and the anterior leaflet with part of posterior leaflet in 4 patients. Associated procedures included aortic valve replacement by a homograft (n = 4) and pulmonary valve reconstruction (n = 1).

Results. No hospital deaths are reported. One late death, at 16 months, is reported after reoperation due to recurrent aortic valve endocarditis. At midterm (mean follow-up, 30 months) patients had excellent functional status and normal valvular function during echocardiographic studies.

Conclusions. We conclude that when the degree of tricuspid valve destruction prevents repair, partial homograft replacement can be used as an extension of the already existing reconstructive techniques, with excellent functional results.     

Early surgery for active infective endocarditis.

OBJECTIVE: The timing of surgery for active infective endocarditis remains controversial. In this report, we have reviewed 26 patients who underwent surgery for active infective native-valve endocarditis between April 1992 and December 1998. PATIENTS AND METHOD: There were 19 male and 7 female patients (mean age 45 years). The aortic valve was involved in 8 patients, the mitral valve in 6 patients, tricuspid valve in 2 patients, both aortic and mitral valves in 7 patients, both aortic and tricuspid valve in 2 patients, and both mitral and tricuspid valve in one patient. The most common microorganisms were streptococcal species. Preoperative high New York Heart Association functional class (III and IV) was presented in 20 patients (77%). Progressive heart failure and the echocardiographic findings of vegetation (larger than 1 cm) were the main operative indications. Emergency or urgent surgery was required in 18 patients (70%). All patients underwent valve replacement, involving 25 mechanical prosthesis and 8 bioprosthesis. RESULTS: The operative mortality was 7.8% (n = 2). In the two patients who died, the infection had extended to the deep cardiac tissue and to the cerebral artery. The mean follow-up of the 24 survivors was 33 months (range from 6 to 82 months). There was no late death and no recurrence of infective endocarditis. CONCLUSION: In case of active infective endocarditis, early surgical intervention is recommended in patients with rapidly progressive cardiac deterioration or vegetation seen on echocardiography.     

Management of quadruple valves for severe infective endocarditis; report of a case

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.     

Homograft replacement of the mitral valve: eight-year results

OBJECTIVE: The objective of this study was to assess whether the mitral homograft represents a valuable alternative for complete or partial mitral valve replacement. METHODS: Since 1993, 104 patients underwent mitral homograft replacement surgery. The mean age was 38 +/- 15 years. The causes of mitral valve disease were rheumatic disease (n = 76), infective endocarditis (n = 24), and others (n = 4). Sixty-five of these procedures were total homografts, and 39 were partial homografts. RESULTS: The mean follow-up was 52 +/- 35 months (maximum, 117 months). Overall hospital mortality was 4 (3.8%) of 104 patients and 2.5% versus 8.7% for patients without endocarditis and with endocarditis, respectively (P <.19). There were 9 late deaths (cardiac, 4; noncardiac, 5). There have been 5 early (<3 months) and 10 late reoperations. Of the remaining 77 patients, New York Heart Association class was I in 61, II in 14, and III in 2. Four patients had endocarditis, and 5 had an ischemic or hemorrhagic event. Freedom from major cardiac events was 71% +/- 6% at 8 years (partial at 81% vs total at 63%, P <.19). Among patients with a total homograft, freedom from major cardiac events was 61% +/- 9% and 85% +/- 8% at 6 years in patients younger than and older than 40 years, respectively (P =.09). CONCLUSION: The risk of early dysfunction related to a mismatch between the mitral homograft and the patient's valve is the main pitfall of the technique. Beyond that stage, the results were comparable with those of bioprostheses in a cohort of young patients.     

Stentless tricuspid valve replacement

Stentless tricuspid valve replacement was performed in a 21-year-old patient with severe destructive tricuspid valve endocarditis resistant to medical therapy. Postoperative recovery was uneventful. Stentless atrioventricular valves are considered an additional treatment option besides stented valves or homograft implantations for severe right-sided endocarditis. Transvalvular hemodynamics are excellent, and right ventricular function can be preserved by suspending the valve at the papillary muscles.     

More than ten years' follow-up of the Hancock porcine bioprosthesis in Japan.

From February 1975 through October 1981, 256 Hancock porcine bioprostheses (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) (60 aortic, 169 mitral, and 27 pulmonary/tricuspid position) were implanted in 220 patients (104 male and 116 female, aged 9 to 67 years; mean 43.3) at Kyushu University Hospital in Japan. The procedures include 41 aortic valve replacements, 121 mitral valve replacements, 4 pulmonary valve replacements, 6 tricuspid valve replacements, and 48 combined valve replacements (31 aortic plus mitral, 13 mitral plus tricuspid, and 4 aortic plus mitral plus tricuspid). Hospital mortality was 6.4%. Follow-up was 98% during 8 to 14 (mean 10.5) years. Cumulative follow-up was 1836 patient-years and 2078 valve-years. At 10 years the overall actuarial survival rate, including hospital morality, was 70% +/- 3%, and freedom from valve-related mortality with sudden death was 87% +/- 3%. More than half of the current survivors required no anticoagulant therapy. Freedom from thromboembolism or anticoagulant-related hemorrhage (or both) and prosthetic valve endocarditis was common. Freedom from structural valve failure and reoperation declined more than 9 years after replacement of left-sided heart valves but not after replacement of right-sided heart valves. Sixty-seven patients underwent 68 repeat operations, and there were four deaths (5.9%). The rate of freedom from overall valve-related complications at 10 years was 62% +/- 8% for aortic valve replacement, 53% +/- 5% for mitral valve replacement, 80% +/- 13% for pulmonary/tricuspid valve replacement, and 42% +/- 9% for combined valve replacement. There was a significant difference between pulmonary/tricuspid valve replacement and combined valve replacement (p less than 0.05). The Hancock bioprosthesis is suitable for the replacement of valves in the right side of the heart but not for combined valve replacement.     

Redo aortic root surgery for failure of an aortic homograft is a major technical challenge

OBJECTIVE: Aortic homografts offer many advantages over prosthetic valves. However, homograft dysfunction due to degeneration or infection may lead to reoperation. Aortic valve replacement in patients who have undergone previous aortic root replacement with an aortic homograft remains a technical challenge. To assess reoperation events a retrospective review was conducted. MATERIALS AND METHODS: From January 2000 to October 2006, 20 consecutive patients (38.8+/-14.9 years old) underwent repeat surgery for aortic homograft failure. RESULTS: Reoperation was performed 7.2+/-3.5 years after implantation of the aortic homograft as a root. Indication was homograft degeneration (n=18 [90%]) and endocarditis (n=2 [10%]). In patients with major homograft wall calcifications or endocarditis, nine aortic root reconstructions were performed (Bentall procedure n=7; homograft implantation n=2). Each homograft was dissected with electrical cauterization and removed 'en-bloc' sparing the coronary buttons. In case of flexible homograft wall, stented prostheses (mechanical n=10, bioprosthesis n=1) were implanted along the homograft annulus. Additional procedures consisted of mitral valve replacements (n=8), tricuspid repairs (n=4), Konno procedure (n=1) and coronary bypass (n=5). Perioperative complications occurred in seven (35%) patients: sternal re-entry accident (n=2); reoperations for mediastinitis (n=1) or bleeding (n=2); renal insufficiency (n=1); total heart block (n=1). No association was found between operative procedures and postoperative complications (Fisher's exact test). Two patients (10%) died from multiorgan failure in the early postoperative period. In total, 94.4% of the survivors remained free from reoperation at 74 months. CONCLUSION: Reoperation on patients with an aortic homograft as a root presents a relatively high perioperative morbidity. The surgical strategy depends on the degree of homograft wall calcification.     

Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve "recycling"

Tricuspid valve endocarditis traditionally has been treated with either valve excision or valve replacement. To avoid implantation of foreign material in an infected field, we have applied the principles of mitral valve repair to 4 patients with tricuspid valve endocarditis. On preoperative echocardiography, all patients had 3 to 4+ tricuspid regurgitation, evidence of progressive right ventricular enlargement, and mobile vegetations. In each case, up to three quarters of the anterior leaflet was excised en bloc with infected chordae and papillary muscle heads. Surgical procedures included standard quadrangular resection, conversion to a bicuspid valve, and pericardial patch replacement of the anterior leaflet with mobilization of basal chordae to replace resected marginal chordae. On postoperative echocardiography, tricuspid regurgitation and right ventricular dimensions were reduced in 2 of 4 patients in spite of loss of leaflet tissue. All excised valve tissue demonstrated bacteria on Gram stain or culture. Nonetheless, all repaired valves were successfully sterilized without recurrent infections. Tricuspid valve repair can allow eradication of infection with potential for improving valve competency in complicated tricuspid valve endocarditis.     

Reoperations in valvular heart disease

Background Reoperations for valvular heart disease are associated with a higher overall mortality than the primary operations. In this retrospective analysis, we present our experience of reoperative valvular heart surgery over a period of 25 years. Methods From January 1975 to July 2000, 13039 operations were performed for valvular heart disease. Of these 665 were reoperations. The mean age of the patients at the primary operation was 24.0±10.2 years (range: 8 to 65 years) and at re-operation was 35.6±11.6 years (range: 9 to 65 years) with an interval of 9.4±2.2 years (range: 0.2 to 25 years) between the 2 procedures. Four hundred and forty reoperations were performed following a previous closed mitral valvotomy and procedures included, redo closed mitral valvotomy (n=28), mitral valve replacement (n=30), open mitral commissurotomy (n=51), mitral valve repair (n=9), homograft mitral valve replacement (n=2), double valve replacement (n=47), aortic valve replacement (n=2) and homograft aortic valve replacement plus open mitral commissurotomy (n=l). Eighty six patients underwent reoperations following mitral valve replacement. Valve thrombosis (n=50) and endocarditis (n=10) were principle causes of reoperation. Forty three patients required reoperation following failed mitral valve repair, 19 following open mitral commissurotomy and 8 following homograft mitral valve replacement. Sixty five patients underwent reoperation following aortic valve operations: prosthetic aortic valve replacement in 43, homograft aortic valve replacement in 5, aortic valve repair in 10, and Ross procedure in 7. Results Majority of patients were operated through midsternotomy. Aortic cannulation was possible in all but 4 patients in whom femoral artery cannulation was required. Operative mortality following reoperations was 7.5% (n=50). Peri-operative bleeding, low cardiac output and infective endocarditis were major causes of operative deaths. Other post-operative complications included cerebrovascular accident (n=3), acute renal failure (n=10) and jaundice (n=25). Fifteen patients developed significant wound infection. Conclusions Patients undergoing operation for valvular heart disease frequently require reoperation. Reoperative valvular heart surgery is safe and can be undertaken with acceptable mortality and morbidity.     

Extracardiac Right Atrium-to-Right Ventricle Homograft for Uncorrectable Tricuspid Valve Disease

Surgically uncorrectable tricuspid valve disease in children is rare. However, when it happens the surgical options are very limited. Tricuspid valve replacement using a mechanical valve or stented bioprosthesis is impractical. Use of homografts in the “anatomic position” has its limitations. We report here the use of an extracardiac homograft connection between the right atrium and right ventricle in a 16-month-old boy in whom severe tricuspid valve stenosis developed after surgical repair of a complex ventricular septal defect associated with dextrocardia and anomalous systemic venous drainage. The patient remains well receiving no cardiac medication 12 months after the procedure.     

A review of surgery for acquired tricuspid valve disease, including an assessment of the stented semilunar homograft valve, and the results of operation for multivalvular heart disease

A total of 246 operations were performed in 230 patients for correction of acquired tricuspid valve disease. All but three of the patients had multivalvular heart disease. There was an 11% hospital mortality which fell to 7% in the later era (1973-82). Mortality was similar for tricuspid annuloplasty and tricuspid replacement and for double and triple valve surgery. On multivariate analysis the incremental risk factors for hospital death were extreme functional disability (Class V), being of Caucasian race, and having a high cardiothoracic ratio (CTR). Actuarial survival was 58% at 9 years postoperative. The incremental risk factors for late death were prior cardiac surgery, age at operation greater than or equal to 55 years, and advanced functional disability (Classes IV, V). The actuarial incidence of significant tricuspid incompetence following annuloplasty was 12% at 3 years, and following stented homograft semilunar valve replacement was 6% at 3 years and 24% at 8 years. Severe homograft valve incompetence was always associated with recurrent left-sided valve lesions or residual pulmonary hypertension. It is concluded that a homograft valve is a superior form of tricuspid valve replacement.     

Tricuspid bioprosthesis replacement with cryopreserved mitral homograft.

We report the case of replacement of a dysfunctional tricuspid Hancock bioprosthesis by a cryopreserved mitral homograft. Tricuspid bioprosthesis was approached on a beating heart. The mitral homograft was orientated so as the anatomic anterior leaflets corresponding and a semi rigid prosthetic ring was inserted. At 1 year follow-up, the patient's clinical condition and echocardiographic results were satisfactory.     

三尖瓣替换术及早期结果

目的 探讨三尖瓣替换术（TVR）的手术适应证和人工瓣膜的选择。方法 1997年3月至2004年6月,共施行TVR42例,其中20例有心脏手术史。手术适应证：①自然瓣膜损毁无法修复（34例）;②进行性三尖瓣病变（2例）;③修复后残余的瓣膜功能不全仍严重影响心脏功能（6例）。合并下列情况时,积极选择TVR：肺血管阻力中、重度升高;手术后有残余的左心功能不全;有三尖瓣成形手术史。人工心脏瓣膜替换术包括：单纯TVR30例,主动脉瓣和二尖瓣加TVR8例,二尖瓣加TVR3例,主动脉瓣加TVR1例。三尖瓣位人工瓣使用双叶型机械瓣28枚,生物瓣14枚。其他合并的心脏手术包括：先天性心脏畸形修复10例,人工瓣周漏修补、黏液瘤切除、冠状动脉搭桥各1例。结果 全组手术病死率17％（7／42）,手术并发症发生率31％（13／42）。术后心功能（NYHA分级）：Ⅰ级21例,Ⅱ级10例,Ⅲ、Ⅳ级各1例。术后晚期死亡2例。结论 当三尖瓣的病变程度严重,修复把握不大,特别是伴有肺血管病变、左心功能不良、左心病变未能完全矫治时,应积极行TVR;人工瓣应选择双叶型和机械瓣或生物瓣,特别是后者。     

Combined multiple-valve procedures. Factors influencing the early and late results

The early and late results were retrospectively evaluated in 57 cases of double or triple valve replacement or repair performed in 1970-1983. The causes of the valvular lesions were rheumatic fever (43 cases), bacterial endocarditis (6), syphilis (1) and unknown (7 cases). The preoperative NYHA classification was III in 29 patients and IV in 28, due mainly to dyspnea of effort. Cardiomegaly (mean radiologic volume 880 cm3/m2) and atrial fibrillation were the dominant clinical findings. Surgery was on emergency indications in five cases. Cold cardioplegia combined with external cardiac cooling has been used for myocardial protection since 1977. The valve replacements were 56 aortic, 50 mitral and 2 tricuspid. In addition there were three closed and two open mitral commissurotomies, two mitral plastic repairs, three tricuspid valve anuloplasties (DeVega) and one aortic anuloplasty. Follow-up (0.3-13, mean 3.5 years) was supplemented with a check-up including two-dimensional echophonocardiography and hematologic tests. The operative mortality (10/57 patients) fell from 26% in 1970-1976 to 12% in 1977-1983. The causes of death were low cardiac output in preoperatively ill patients (5), myocardial infarction (2), technical failure (2) and sepsis (1 case). There were 11 late deaths (6.7/100 patient-years of observation), the commonest cause (5 patients) being congestive heart failure. The respective incidences of thromboembolism, paravalvular leak and postoperative endocarditis were 2.1, 4.2 and 2.1 episodes/100 patient-years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mitral valve replacement with homograft

The technique for replacement of the mitral valve with a mitral valve homograft is described. Principles include side-by-side approximation of the papillary muscles using multiple stitches of fine monofilament suture, direct attachment of the annulus of the mitral homograft to the annulus of the patient, and support of the repair by remodeling annuloplasty ring.     

Percutaneous balloon valvuloplasty of a stenosed bioprosthesis (Carpentier-Edwards xenograft) in the tricuspid valve position

Two patients with increasing stenosis of a bioprosthesis in the tricuspid valve position were treated by percutaneous balloon valvuloplasty (PBV). Tricuspid valve replacement with a Carpentier-Edwards xenograft and mitral valve replacement with a Duromedics mechanical valve had been performed in both of them 2 to 3 years prior to PBV. Echocardiographic studies revealed tricuspid bioprosthetic stenosis with a prolonged pressure half time. After PBV, the calculated valve area and cardiac index increased and the pressure half time was shortened, although improvement of clinical symptoms was not apparent. Complications related to the procedure did not occur. Further studies are required to determine the indications and to see the long term results of PBV on stenosed bioprosthesis in the tricuspid valve position, but for the moment, we consider PBV be tried with caution for a stenosed bioprosthesis in the tricuspid valve position before the decision for re-replacement of the prosthesis.     

Triple-valve treatment for prosthetic valve endocarditis occurring 20 years after implantation of a Carpentier-Edwards pericardial bioprosthesis in the aortic valve

A 68-year-old woman had undergone aortic valve replacement and open commissurotomy 20 years previously. At the beginning of 2008, fever, cold, and heart failure symptoms were noted. On blood culture, Streptococcus oralis was detected three times. Surgery was performed under a diagnoses of prosthetic valve endocarditis in the aortic valve, mitral stenosis and insufficiency, and tricuspid insufficiency. Techniques consisted of additional aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Vegetation was macroscopically and pathologically observed in the extirpated Carpentier-Edwards pericardial bioprosthesis that had been placed in the aortic valve. There was no postoperative recurrent inflammatory response. The patient was discharged 32 days after surgery.     

Surgical treatment of infective valve endocarditis in children with congenital heart disease

Abstract Objective: This study assesses surgical procedures, operative outcome, and early and intermediate‐term results of infective valve endocarditis in children with congenital heart disease. Methods: Seven consecutive children (five females, two males; mean age, 10.8 years) who underwent surgery for infective valve endocarditis between 2006 and 2010 were included in the study. The aortic and mitral valves were affected in two and tricuspid in five patients. Indications for operation included cardiac failure due to atrioventricular septal rupture, severe tricuspid valve insufficiency, and septic embolization in one, moderate valvular dysfunction with vegetations in three (two tricuspid, one mitral), and severe valvular dysfunction with vegetations in the other three patients (two tricuspid, one mitral). The pathological microorganism was identified in five patients. Tricuspid valve repair was performed with ventricular septal defect (VSD) closure in five patients. Two patients required mitral valve repair including one with additional aortic valve replacement. Results: There were no operative deaths. Actuarial freedom from recurrent infection at one and three years was 100%. Early echocardiographic follow‐up showed four patients to have mild atrioventricular valve regurgitation (three tricuspid and one mitral) and three had no valvular regurgitation. No leakage from the VSD closure or any valvular stenosis was detected postoperatively. Conclusions: Mitral and tricuspid valve repairs can be performed with low morbidity/mortality rates and satisfactory intermediate‐term results in children with infective valve endocarditis . (J Card Surg 2012;27:93‐98)     

Is There an Advantage to Repairing Infected Mitral Valves?

Background. The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment.

Methods. Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis.

Results. There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance.

Conclusions. We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.